South Africa: 7.5 Million AIDS Victims in 10 Years

More than 7 million people could be infected with HIV/AIDS in South Africa in the next 10 years, according to a government-sponsored report released Friday. South Africa already had 4 million HIV/AIDS patients by December 2000.

"Between 5.3 and 6.1 million would suffer from HIV/AIDS by 2005, and 6 million to 7.5 million by 2010," according to the research, entitled "Impending Catastrophe Revised." In South Africa, according to the report, almost 25 percent of women ages 15 to 19 would become infected between 1995 and 2010. In comparison, only 5 percent of men in this age group would become infected. However, the male ratio increases to 14.5 percent in the next age group of 20 to 24.

"Women are at greater risk of infection due to biological, social and economic factors," said the report, which was published in the newspaper the Star. AIDS deaths are predicted to rise from 120,000 a year in 2000 to between 354,000 and 383,000 in 2005. The figure could be between 545,000 and 635,000 by 2010.

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Another study quoted by the paper, however, said that AIDS might cause as many as 800,000 deaths by 2010. "Already half of all adult deaths in South Africa can be attributed to AIDS and it will further increase if not checked," the report said. A 15 percent increase in condom use would result in a decrease of 150,000 HIV/AIDS cases among people ages 20 to 25 by 2015, the report predicted. (United Press International, 08.17.01)

GMHC Begins Offering Syphilis Testing

Gay Men's Health Crisis (GMHC), a New York City AIDS service organization, is providing syphilis testing at its David Geffen Testing Center. According to GMHC spokesperson Marty Algaze, the new service, which began Aug. 1, is being offered in response to the increased number of syphilis cases in the city. Health officials recently said that in the first three months of 2001 there were 57 reported cases of syphilis in New York City -- more than double the number reported during the same period last year.

Men account for the majority of those cases during both periods. New York City Health Commissioner Neal Cohen noted earlier this summer that even "as New York City and other parts of the country work toward eliminating syphilis, we have identified an increase in syphilis among MSM [men who have sex with men] whose ages average in the mid-thirties. Additionally, a significant proportion of males infected with syphilis is also infected with HIV. This may reflect an erosion of safer sex practices, which could lead to a rise in the number of syphilis and HIV infections in New York City." (New York Blade, 08.10.01)

Lesson for AIDS Fighters: Syringe Swaps Work

"A decade ago, New Yorkers agonized over whether to provide clean needles to the city's 200,000 people who inject drugs. . . . Their qualms have proved to be not just a little misguided, but dramatically off base -- a fact the policymakers from Queens to Washington ought to ponder.

"In a paper delivered this week to a national HIV prevention conference in Atlanta, Don DesJarlais of New York's Beth Israel Medical Center reported that . . . in 1990, before the state allowed needle-exchange programs, about 50 percent of the city's drug injectors were infected with HIV. By 2000, that ratio had fallen to 20 percent. Meanwhile, the annual infection rate among intravenous drug injectors plummeted from 4 percent a year in 1990 to 1 percent in 2000.

"New York offers a powerful model for other cities now wrestling with a needle-based HIV problem. And yet, the city can't get too caught up in self-congratulation. For one thing -- thanks in part to NIMBY ["not in my back yard"] opposition -- Queens lacks a single syringe-exchange effort. . . . A law that took effect in January does allow pharmacies to sell syringes to drug users, and some Queens outlets are participating in the program.

That's fine, but it isn't enough. A genuine syringe-exchange program also offers counseling and can point drug abusers to an array of ancillary health care services.

"Washington's problem? It is courage. Study after study has shown that the feds should pay for syringe exchanges. But the Clinton White House frantically danced around the idea, and Congress steadily refused to ante up. Maybe the New York study will change some minds." (Newsday (New York), 08.16.01)

Resistance to Needle Exchange in Queens

For more than three years, Philip Glotzer has tried to set up a needle exchange program for drug users in New York City's Queens borough. "People will say they support needle exchange to stop the spread of AIDS in Queens, but nobody wants it in their neighborhood," said Glotzer, the executive director of the AIDS Center of Queens County. "There is resistance from legislators and from the community. We just can't generate support."

AIDS activists and needle exchange advocates believe such resistance is the reason HIV infection rates remain high among intravenous drug users (IDUs) in Queens, Staten Island and Long Island, where there are no such programs. New data made public Monday at the National HIV Prevention Conference in Atlanta showed that infection rates among IDUs in New York City have dropped -- with the exception of areas without exchange sites.

Researchers attributed the decline to participation in the city's 11 needle exchange programs operating in Manhattan, the Bronx and Brooklyn. According to the city health department, almost half of all 120,000 AIDS cases in New York last year were transmitted by intravenous drug use.

A state law that took effect this year allows pharmacies to sell syringes without prescription, but advocates say that many addicts are unaware of the new policy, since the law prohibits advertising. In a new program related to the state law, the AIDS Center of Queens County will supply clean needles, free of charge, at its offices in Rego Park, Jamaica and Far Rockaway.

However, Nassau and Suffolk health offices said that although they do not operate needle exchange programs, the number of AIDS cases diagnosed on Long Island has also fallen significantly. Nassau's caseload dropped from 233 in 1996 to 118 in 1999, while Suffolk's fell from 257 in 1996 to 97 in 1999. (Newsday (New York), 08.14.01, Margaret Ramirez)

Prisons are Breeding Ground for HIV, but Officials Ignore Problem

Although health care workers say jails and prisons are known transfer points for HIV, Florida officials are reluctant to screen inmates for HIV because of the high cost of medicine.

Prisons and jails in Florida test for HIV only if an inmate falls ill or asks for a test. Despite this cost-benefit mentality, however, prison officials also do not distribute the condoms that might prevent HIV's spread. These policies and others are not only endangering inmates but individuals in the communities they return to, says Dr. Anne De Groot, a physician who runs the HIV Prison Project at Brown University. The implications are "huge," De Groot said. "If you don't provide care to those people, if you don't provide education, it really is a problem. People do not stay in corrections forever." Left undetected, sick inmates pass disease to each other and in turn carry AIDS, hepatitis, chlamydia and syphilis back into their communities. One in three hepatitis C cases in the United States occurs in persons who were incarcerated, De Groot said.

In Florida, a US Bureau of Justice survey reported that on June 30, 1999, ten out of 274 prisoners at the Palm Beach County Jail were HIV-positive or showing AIDS symptoms. Eighty Broward County inmates were sick with AIDS, as were 130 Miami-Dade County inmates.

The reported figures are "absolutely the tip of the iceberg," said Dr. Frederick L. Altice, director of the HIV Prisons Project at Yale University. Nationally, scientists know that about 17 percent of people who have HIV were in a correctional facility in the previous year, said Hugh Potter, a researcher with the CDC.

One obvious way of preventing transmission would be to distribute condoms. At least six jails nationwide distribute condoms, including jails in Vermont, San Francisco and at Rikers Island in New York City, according to De Groot. But in Florida, condoms are considered contraband. Inmates save the plastic wrap from sandwiches and use it for protection when having sex, one inmate reported. (Orlando Sentinel, 08.13.01, Stacey Singer; C Ron Allen)

Study: Half of Adult AIDS Patients Suffer from Depression, Anxiety

Nearly half of the nation's adult AIDS patients suffer from symptoms of mental disorders, including depression and anxiety, according to the HIV Cost and Services Utilization Study led by the Rand research organization. The study is based on interviews with nearly 2,900 adults being treated for HIV. The estimates of mental disorders range from four to eight times higher than comparable estimates for the general population. The study's authors also found that one in four used illicit drugs other than marijuana, and more than 12 percent had a drug addiction. The report appears in today's issue of Archives of General Psychiatry (2001; 58: 721-728). (Associated Press, 08.14.01)

Minority Doctors Report Problems

Black and Hispanic doctors across the United States report having greater difficulties than white doctors in obtaining health care for their patients, according to a study published in the online journal Medscape General Medicine. The report, which included 12,300 responses from doctors in 60 communities, found that about 12 percent of black doctors and nearly 15 percent of Hispanic doctors said they had a hard time getting specialty referrals, while about 8 percent of white doctors had that problem. Although blacks and Hispanics make up about 24 percent of the US population, they represent only 10 percent of the doctors surveyed, while white doctors accounted for 76 percent of the group. About 36 percent of black doctors and 32 percent of Hispanic doctors said they could not get their patients into hospitals when necessary. White doctors reported a 24 percent incidence rate of the same problem. Lee Hargraves of the Center for Studying Health System Change was the study's designer and lead author. (Plain Dealer (Cleveland), 08.10.01, Linda Lou)

Ill Omen: Decline of AIDS Levels Off

The dramatic decline in the number of Americans contracting and dying from AIDS has halted, and government officials fear the plateau may signal a new wave in the 20-year-old epidemic. The Centers for Disease Control and Prevention (CDC) announced the shift Monday at a major HIV prevention conference in Atlanta.

"We have made tremendous progress," said Dr. Helene Gayle, the outgoing head of the CDC's National Center for HIV, STD and TB Prevention. "But I think, as you will see from the data that will be presented here, we face a real risk in resurgence of HIV infection in this country."

Overall, the CDC said, 774,467 Americans have been diagnosed with AIDS and 448,060 have died from AIDS since the first cases were reported in 1981. Since 1998, there have been 10,000 new cases and 4,000 AIDS deaths every three months. Except for the period when AIDS new cases and deaths steadily declined from the mid-1990s to 1998, the numbers have remained stable.

In recent years, concern over the persistence of HIV has shifted focus from gay men to closeted bisexuals and their partners, users of injectable drugs, rural residents, and African-American and Latino men and women in communities where sexual activity is not freely discussed. However, gay men remain in danger from a resurgent epidemic, particularly younger men who did not witness the early devastation of the epidemic. Danger signs presented at the conference included:

Almost half of 250 African-American Atlanta women surveyed at Morehouse School of Medicine did not use a condom in any sexual encounter during a two-month period, even though 60 percent did not know their partner's HIV status.

Thirty percent of young men in 13 cities who say they have sex with men had unprotected anal sex with a man during a three-month period, and 17 percent had sex with women during the same period.

More than one in every seven young men in Miami's South Beach who reported having sex with another man at least once was found to be HIV-infected in a study in 1996. More than one in three older men were also HIV-infected.

Thirty percent of men in their 20s who have sex with other men have five or more male partners during a six-month period.

The percentage of HIV-positive men who reported having unprotected anal sex with a partner, whose HIV status was negative, or not known, doubled from 1998 to 2000.

The good news from the front lines of the epidemic, however, is that rates of HIV infection among users of injectable drugs have fallen sharply in New York City neighborhoods, thanks largely to syringe exchanges and counseling. Finally, the proportion of HIV-positive women who pass the virus on to their newborn children has reached a record low thanks to prenatal testing and treatment. (Atlanta Constitution, 08.14.01, M.A.J. McKenna)

High rates of hepatitis B virus (HBV) occur in people who have multiple sex partners, people who have percutaneous blood exposures (those who share injecting drug equipment, and patients on hemodialysis), and health care or public safety workers who have frequent exposure to contaminated blood or other infectious fluids. HBV infection is very common, with more than 350 million chronically infected people worldwide, including 1.25 million in the United States. Twenty to 80 percent of US inmates have past or active HBV infection, and 0.8-1.4 percent of inmates acquire HBV while in prison.

In the correctional environment, tattooing with contaminated needles may be associated with HBV acquisition. Correctional officers may also be at increased risk of HBV infection because of exposure to inmates' blood and other body fluids during the course of their work. Since HIV and HBV have similar modes of transmission, co-infection is quite common. A CDC meeting convened this spring on hepatitis in correctional settings attracted more than 100 federal and state correctional healthcare professionals. CDC speakers discussed the need to expand HBV and hepatitis C virus (HCV) interventions, including screening, education, vaccination and treatment of chronic hepatitis in correctional settings. The CDC will issue guidelines for HCV and HBV management as a supplement to its Morbidity and Mortality Weekly Report in the fall.

Only 25-50 percent of cases of acute HBV are symptomatic; the remainder are asymptomatic or are associated with inconsequential symptoms. Following an incubation period that varies from one week to six months, symptoms of the pre-icteric phase include malaise, weakness, anorexia, nausea, vomiting and upper right quadrant pain. There is no specific therapy for acute viral hepatitis. Supportive therapy including intravenous fluids, antiemetics, mild analgesia, and antipyretics may be necessary in some cases. Avoiding contact with contaminated blood by using universal precautions is the only way to be 100 percent protected against HBV infection.

HIV and HBV interact when they occur in the same host. Like any other infection that occurs in HIV-positive individuals, HBV infection activates the immune system leading to proliferation of CD4 cells which enhances HIV replication and increases plasma HIV RNA (viral load). In addition, HBV proteins directly stimulate HIV replication. Although the literature does not consistently support the presumption that HIV progression is accelerated by concomitant HBV infection, it does appear that HIV infection may accelerate the progression to hepatic failure and hepatic failure-related deaths in patients with chronic HBV infection.

Patients with chronic HBV and HIV are more likely to have clinically significant hepatotoxicity when placed on antiretroviral agents in general and may have increased incidence and severity of indinavir-associated hyperbilirubinemia.

Adults in high-risk groups should be vaccinated but vaccination of all adults is not recommended at this time; older adults are at lower risk. The incidence of acute HBV infection in the United States has declined from 450,000 new infections per year in the 1980s to 80,000 in 1999. Vaccination against HBV, which has been available since 1982, is primarily responsible for this decline. (HIV & Hepatitis Education Prison Project HEPP News, 07.01, Vol 4; No 6/7; P 1-4::David Paar, MD)

Antiretroviral Therapy for Previously Treated Patients

Antiretroviral therapy is most effective the first time it is prescribed. Suppression of plasma HIV-1 RNA to undetectable levels occurs up to 90 percent of the time when patients begin their first triple-drug regimen. Achieving this level of suppression decreases with each subsequent treatment regimen, with only one-third or less of patients having previous exposure to two or more classes of antiretroviral drugs achieving undetectable levels of HIV-1 RNA.

In their editorial responding to the Albrecht et al. article in this issue of NEJM, Montaner and Mellors stress that the overall response rate of patients with persistent viremia in the quadruple-therapy group (participants who received nelfinavir, efavirenz and two nucleoside reverse-transcriptase inhibitors) points to "the importance of prescribing, whenever possible, at least two drugs of new classes for patients who have already received treatment. . . ." In patients with previous exposure to all three classes of antiretroviral drugs, "regimens containing four or five drugs have achieved suppression of viral replication in only 15 percent of patients. This response rate is dismal and warrants a call to action for clinicians, scientists, and leaders in industry and government."

"What can be done for this most challenging group of patients?" the authors ask. While encouraging preliminary results indicate success with multi-drug regimens of six or more approved antiretroviral drugs, the approach can cause serious toxic effects. High levels of exposure to drugs may help to overcome moderate drug resistance and "the use of ritonavir to boost the serum levels of other protease inhibitors has improved the rates of viral suppression in patients in whom regimens containing protease inhibitors have previously failed."

The promise of new agents is no guarantee of success, since the staggered release of new antiretroviral agents into clinical practice "often results in the addition of only one new drug at a time to a failing regimen, rather than the more effective simultaneous addition of at least two new drugs, as illustrated by Albrecht et al.," the authors argue. Finally, there is the problem of the lack of any requirements for studying new antiretroviral agents in patients with previous exposure to all three classes of drugs. "The current regulatory requirements are not helping the most desperate patients. We need greater cooperation among academic, industry and regulatory agencies to improve the outlook for patients for whom effective treatment options are currently lacking," say the authors. (New England Journal of Medicine, 08.09.01, Vol. 345; No. 6; p. 452-461, Julio S.G. Montaner, M.D.; John W. Mellors, M.D.)

Practical Prevention of Vaginal and Rectal Transmission of HIV by Adapting the Oral Defense: Use of Commercial Lubricants

HIV is transmitted to 6.4 million people each year, primarily via sex. Condoms, which are highly effective, are recommended as the primary preventive. However, the fact that millions of sexual transmissions occur each year indicates that many people do not use condoms, and additional preventives are thus needed. Hypotonic saliva, which preferentially inhibits HIV production by infected leukocytes by 10,000-fold, appears to contribute to the rarity of oral transmission. The mechanisms of natural prevention of oral transmission by saliva may be adaptable to the susceptible vagina and rectum. The objective of this study was to reduce sexual transmission of HIV by mimicking saliva's targeting of the transmitting infected leukocytes and any cell-free HIV in seminal fluid.

The previously recommended anti-HIV topical microbicide, nonoxynol-9, has not prevented HIV transmission in humans, probably because it causes mucosal irritation and attracts CD4+ cells. To identify an effective but non-irritating preparation, the researchers studied commercial, over-the-counter (OTC) lubricants and vaginal preparations that are in the safest US Food and Drug Administration (FDA) category and do not cause irritation when used repeatedly by large numbers of people. For their study, the researchers purchased 22 OTC topical preparations. The effect of OTC preparations on both the production of HIV by infected leukocytes and cell-free HIV suspended in seminal fluid was measured under simulated in vivo conditions. Researchers excluded preparations with low inhibitory activity and those that were inhibitory but likely to be irritating.

Three OTC products were found to be highly active against both HIV-infected leukocytes suspended in seminal fluid and active against cell-free HIV under in vitro conditions that simulate in vivo conditions. These products were Astroglide vaginal lubricant, Vagisil vaginal moisturizer and ViAmor vaginal moisturizer.

"Overall, these three OTC preparations have desirable properties, which should make them candidates for trials in humans. The attributes of these OTC preparations include being widely available, inexpensive, acceptable, in the safest US FDA category, and usable by recipient women and men. We believe that the World Health Organization, government agencies, and pharmaceutical companies should strongly consider field trials in people at risk," the researchers concluded. (AIDS Research and Human Retroviruses, 07.01, Vol 17; No 11: p. 997-1002, Samuel Baron; Joyce Poast; Derrick Nguyen; Miles W. Cloyd)

Unsafe Sex Among HIV-Positive Men

Since April, at least three Iowa men have told police they believed Aaron Dahlberg when he told them he was HIV-negative before having unprotected sex with them. Now the Inver Grove Heights man faces up to 25 years in prison if convicted of an Iowa charge of criminal transmission of HIV. Dahlberg is free on $35,000 bond. Karen Egerton, a prosecutor for Iowa's Johnson County, said all of Dahlberg's accusers have so far tested negative, although the law does not require that victims be infected in order to prosecute.

While Dahlberg says he's innocent, others say the case illustrates a disturbing new trend. After nearly 20 years and millions of dollars spent on AIDS awareness, an increasing number of HIV-positive gay and bisexual men are having unprotected sex, experts say. Since the beginning of AIDS awareness nearly two decades ago, HIV prevention efforts have almost exclusively targeted one group: the uninfected. The new trend has forced the CDC and the National Institutes of Health to rethink their target audience. The CDC's education plan through 2005 now includes "a priority on prevention" for HIV-positive people.

Russ Lovaasen, a healthy-looking Minneapolis resident, has lived with HIV for 19 years. Sometimes he drops clues, such as sporting a rainbow-colored necklace adorned with a red ribbon -- the international AIDS-awareness symbol. For many HIV-positive people, Lovaasen said the fear of rejection fuels the decision to keep quiet. Sometimes that means putting others at risk. Simon Rosser, director of the HIV/STI Intervention and Prevention Studies Center at the University of Minnesota, said "very, very few" people with HIV want to pass it on to others, so they're willing to take precautions. "But every now and then, you just want sex to be spontaneous, beautiful, wonderful. That's what people with HIV want, too. I'm not saying it's right or wrong -- it's just something to understand," Rosser said.

Immunologic Profile of HIV-Infected Patients During Viral Remission and Relapse on Antiretroviral Therapy

Highly active antiretroviral therapies (HAART) potently suppress plasma human immunodeficiency virus (HIV) RNA levels. Many patients who achieve suppression, however, suffer viral relapse to detectable levels of the virus. Current understanding of the relationship between viral and immune pathogenesis is based primarily on natural history studies and studies of treatment initiation.

HIV disease progression is marked by a decline in both naive and memory CD4+ lymphocyte sub-populations. When antiretroviral therapy is initiated, CD4+ lymphocytes rapidly increase, and this increase is restricted to the memory sub-populations, followed by slower increases in naive lymphocytes over a more prolonged period.

The current pilot study assessed HIV-infected patients receiving antiretroviral therapy with stable suppressed virus (stable suppressed group) and patients experiencing viral relapse (viral relapse group). All patients were recruited from the Duke University Adult Infectious Diseases Clinic (Durham, N.C.). The stable suppressed group included patients on therapy for three months, whose most recent plasma HIV RNA level was <500 copies/mL. Patients in the relapse group had 1 plasma HIV RNA level <500 copies/mL while receiving antiretroviral therapy. In addition, their most recent plasma HIV RNA level was >500 copies/mL. Patients were excluded from the study if they had an active AIDS-defining illness or other acute illness or if they had any change in antiretroviral therapy since last achieving a plasma HIV RNA level <500 copies/mL.

Blood samples were obtained from patients at a single time point, which was defined as "study entry." Laboratory measurements included immunophenotyping, plasma HIV RNA levels (Amplicor; lower limit of detection, 400 copies/mL), and T cell receptor excision circle (TREC) analysis.

According to the authors, the study was small and included only 28 patients: "10 in the stable suppressed group and 18 in the viral relapse group. Although the viral relapse group had fewer men, 11 (61%) of 18, compared with 9 (90%) of 10, the groups were statistically similar with regard to sex, age, and race (P = .105, P = .999, and P = .283, respectively). The median age was 43.1 years (range, 22.3-56.7 years); 15 (54%) of 28 patients were black.

"The groups had similar antiretroviral treatment histories. Overall, 18 (64%) of 28 were receiving a protease inhibitor containing regimen, and 21 (75%) of 28 were receiving >3 antiretroviral medications." Longitudinal analyses show that both groups had stable or increasing CD4+ cell counts.

According to the study results, "The rate of change in CD4+ cells/week was significantly lower in the viral relapse group, compared with that in the stable suppressed group (P = .043). At study entry, the viral relapse group and stable suppressed group had similar CD4+ lymphocyte counts (407 vs. 562 cells/mm; P = .175). However, the viral relapse group had significantly fewer CD4+ lymphocytes (20% vs. 32%; P = .015)." While naive CD4+ lymphocyte phenotype and TREC levels were not significantly different in patients with virus suppression or in those who had relapsed, "CD8+ lymphocyte activation, including the number and percentage of activated cells and CD38 antibody-binding capacity, was significantly elevated during viral relapse, compared with that in suppressed patients. By multivariable regression analyses, CD8+ and CD4+ lymphocyte activation were associated significantly with increasing plasma HIV RNA levels."

The authors assume that CD8+ lymphocyte activation in persons with viral relapse directly reflects increasing HIV replication in a manner similar to the relationship observed during an acute HIV infection. According to them, "Prior research has shown that increases in CD8+ lymphocyte activation do not coincide with immediate reductions in circulating CD4+ lymphocytes or progression to clinical AIDS-related events. However, over the longer term, increased CD8+ lymphocyte activation is associated with functional immune impairment and clinical disease progression." (Journal of Infectious Diseases, 05.15.01, 2001; 183: 1522-1525. Melissa F. Wellons et al.)

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